Produção Nacional
Revisado por pares
Pulmonary Instillation of Activated Charcoal: Early Findings on Computed Tomography
2011; Elsevier BV; Volume: 91; Issue: 2 Linguagem: Inglês
10.1016/j.athoracsur.2010.06.064
ISSN1552-6259
AutoresLuiz Felipe Nobre, Edson Marchiori, Ângelo Duarte Carrão, Gláucia Zanetti, Cláudia Mauro Mano,
Tópico(s)Trauma Management and Diagnosis
ResumoWe read with great interest the uncommon case reported by Huang and colleagues [1Huang C.C. Wu H.S. Lee Y.C. Extensive tracheobronchitis and lung perforation after alkaline caustic aspiration.Ann Thorac Surg. 2010; 89: 1670-1673Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar], who described life-threatening acute respiratory complications, with corrosive tracheobronchitis and lung perforation, after caustic aspiration during a suicide attempt. They affirm that although caustic aspiration is frequent because of vomiting and pharyngolaryngeal edema, it may happen at the moment of laryngeal phase of swallowing. We would like to share our experience in another case of suicide attempt with pulmonary and pleural involvement secondary not to the aspiration of the drug, but to the treatment.A 23-year-old woman presented to the emergency department approximately 90 minutes after attempting suicide by ingesting 10 tablets of paroxetine (20 mg), a selective serotonin uptake inhibitor antidepressant. She underwent gastric lavage and instillation of 1.5 liters of activated charcoal through a nasogastric tube. Subsequently, a dry cough, right-sided thoracic pain, and dyspnea developed.A chest roentgenogram revealed a pleural effusion, without pneumothorax. Thoracentesis showed a black material, which was identified as charcoal. A chest computed tomography scan showed a dense pleural effusion and a dense pulmonary consolidation in the right lower lobe (attenuation values of approximately 130 Hounsfield units). Bronchoscopy revealed the presence of black material emerging from the right lower pulmonary lobe. Air leakage from the chest tube was suggestive of the presence of a bronchopleural fistula. The patient underwent pleuroscopy with extensive pleural lavage. On day 15, after natural closure of the fistula, the thoracic drain was removed, and the patient was discharged.Activated charcoal is a safe, effective, and inexpensive antidote for most toxic ingestions. Little information is available on associated complications [2Menzies D.G. Busuttil A. Prescott L.F. Fatal pulmonary aspiration of oral activated charcoal.BMJ. 1988; 297: 459-460Crossref PubMed Scopus (59) Google Scholar]. Pulmonary aspiration of charcoal is a rare complication after treatment for toxic ingestions. Most pulmonary complications are considered to result from the aspiration of gastric contents along with the charcoal, and not from direct aspiration of the charcoal [3Graff G.R. Stark J. Berkenbosch J.W. Holcomb 3rd, G.W. Garola R.E. Chronic lung disease after activated charcoal aspiration.Pediatrics. 2002; 109: 959-961Crossref PubMed Scopus (28) Google Scholar]. However, the nasogastric tube can be erroneously placed into the trachea, and direct administration of charcoal into the airways can result in a serious outcome. Another complication related to the accidental airway instillation is pleural involvement. Pneumothorax, pleural effusions with the presence of charcoal, and persistent bronchopleural fistula are probably secondary to the instillation of a large volume of charcoal solution into the distal airways [4Seder D.B. Christman R.A. Quinn M.O. Knauft M.E. A 45-year-old man with a lung mass and history of charcoal aspiration.Respir Care. 2006; 51: 1251-1254PubMed Google Scholar].Only two prior studies have addressed the lung alterations observed on computed tomography after activated charcoal aspiration, both concerned to long-term consequences [3Graff G.R. Stark J. Berkenbosch J.W. Holcomb 3rd, G.W. Garola R.E. Chronic lung disease after activated charcoal aspiration.Pediatrics. 2002; 109: 959-961Crossref PubMed Scopus (28) Google Scholar, 4Seder D.B. Christman R.A. Quinn M.O. Knauft M.E. A 45-year-old man with a lung mass and history of charcoal aspiration.Respir Care. 2006; 51: 1251-1254PubMed Google Scholar]. In one report, a mass was detected in the right lower lobe 2 years after charcoal aspiration [4Seder D.B. Christman R.A. Quinn M.O. Knauft M.E. A 45-year-old man with a lung mass and history of charcoal aspiration.Respir Care. 2006; 51: 1251-1254PubMed Google Scholar]. In the other, a “tree-in-bud” pattern was observed 4 years after charcoal aspiration [3Graff G.R. Stark J. Berkenbosch J.W. Holcomb 3rd, G.W. Garola R.E. Chronic lung disease after activated charcoal aspiration.Pediatrics. 2002; 109: 959-961Crossref PubMed Scopus (28) Google Scholar]. With this report, we demonstrate the presence of high-density pleural effusion and high-density pulmonary consolidation as early chest computed tomography abnormalities after accidental charcoal instillation.In conclusion, the presence of high-density material in the lung parenchyma or in the pleural space in patients treated with activated charcoal is suggestive of accidental activated charcoal instillation. We read with great interest the uncommon case reported by Huang and colleagues [1Huang C.C. Wu H.S. Lee Y.C. Extensive tracheobronchitis and lung perforation after alkaline caustic aspiration.Ann Thorac Surg. 2010; 89: 1670-1673Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar], who described life-threatening acute respiratory complications, with corrosive tracheobronchitis and lung perforation, after caustic aspiration during a suicide attempt. They affirm that although caustic aspiration is frequent because of vomiting and pharyngolaryngeal edema, it may happen at the moment of laryngeal phase of swallowing. We would like to share our experience in another case of suicide attempt with pulmonary and pleural involvement secondary not to the aspiration of the drug, but to the treatment. A 23-year-old woman presented to the emergency department approximately 90 minutes after attempting suicide by ingesting 10 tablets of paroxetine (20 mg), a selective serotonin uptake inhibitor antidepressant. She underwent gastric lavage and instillation of 1.5 liters of activated charcoal through a nasogastric tube. Subsequently, a dry cough, right-sided thoracic pain, and dyspnea developed. A chest roentgenogram revealed a pleural effusion, without pneumothorax. Thoracentesis showed a black material, which was identified as charcoal. A chest computed tomography scan showed a dense pleural effusion and a dense pulmonary consolidation in the right lower lobe (attenuation values of approximately 130 Hounsfield units). Bronchoscopy revealed the presence of black material emerging from the right lower pulmonary lobe. Air leakage from the chest tube was suggestive of the presence of a bronchopleural fistula. The patient underwent pleuroscopy with extensive pleural lavage. On day 15, after natural closure of the fistula, the thoracic drain was removed, and the patient was discharged. Activated charcoal is a safe, effective, and inexpensive antidote for most toxic ingestions. Little information is available on associated complications [2Menzies D.G. Busuttil A. Prescott L.F. Fatal pulmonary aspiration of oral activated charcoal.BMJ. 1988; 297: 459-460Crossref PubMed Scopus (59) Google Scholar]. Pulmonary aspiration of charcoal is a rare complication after treatment for toxic ingestions. Most pulmonary complications are considered to result from the aspiration of gastric contents along with the charcoal, and not from direct aspiration of the charcoal [3Graff G.R. Stark J. Berkenbosch J.W. Holcomb 3rd, G.W. Garola R.E. Chronic lung disease after activated charcoal aspiration.Pediatrics. 2002; 109: 959-961Crossref PubMed Scopus (28) Google Scholar]. However, the nasogastric tube can be erroneously placed into the trachea, and direct administration of charcoal into the airways can result in a serious outcome. Another complication related to the accidental airway instillation is pleural involvement. Pneumothorax, pleural effusions with the presence of charcoal, and persistent bronchopleural fistula are probably secondary to the instillation of a large volume of charcoal solution into the distal airways [4Seder D.B. Christman R.A. Quinn M.O. Knauft M.E. A 45-year-old man with a lung mass and history of charcoal aspiration.Respir Care. 2006; 51: 1251-1254PubMed Google Scholar]. Only two prior studies have addressed the lung alterations observed on computed tomography after activated charcoal aspiration, both concerned to long-term consequences [3Graff G.R. Stark J. Berkenbosch J.W. Holcomb 3rd, G.W. Garola R.E. Chronic lung disease after activated charcoal aspiration.Pediatrics. 2002; 109: 959-961Crossref PubMed Scopus (28) Google Scholar, 4Seder D.B. Christman R.A. Quinn M.O. Knauft M.E. A 45-year-old man with a lung mass and history of charcoal aspiration.Respir Care. 2006; 51: 1251-1254PubMed Google Scholar]. In one report, a mass was detected in the right lower lobe 2 years after charcoal aspiration [4Seder D.B. Christman R.A. Quinn M.O. Knauft M.E. A 45-year-old man with a lung mass and history of charcoal aspiration.Respir Care. 2006; 51: 1251-1254PubMed Google Scholar]. In the other, a “tree-in-bud” pattern was observed 4 years after charcoal aspiration [3Graff G.R. Stark J. Berkenbosch J.W. Holcomb 3rd, G.W. Garola R.E. Chronic lung disease after activated charcoal aspiration.Pediatrics. 2002; 109: 959-961Crossref PubMed Scopus (28) Google Scholar]. With this report, we demonstrate the presence of high-density pleural effusion and high-density pulmonary consolidation as early chest computed tomography abnormalities after accidental charcoal instillation. In conclusion, the presence of high-density material in the lung parenchyma or in the pleural space in patients treated with activated charcoal is suggestive of accidental activated charcoal instillation. ReplyThe Annals of Thoracic SurgeryVol. 91Issue 2PreviewWe appreciate Nobre and colleagues' [1] experience regarding our article [2]. Various types of damage of the respiratory system may occur during corrosive ingestion, as well as therapeutic gastric lavage. Nasogastric tubes can inadvertently pass through the tracheobronchial tree perforating into the pleural space [3, 4]. Dense charcoal in pleural effusion and lung consolidation are probably secondary to the instillation of a large volume of charcoal solution into the distal airways. Besides, pneumothorax and pleural effusions indicate the presence of bronchopleural fistula. Full-Text PDF
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